Surviving Wonderland

I Ride GreyhoundBecause it’s like being In a John Steinbeck novel. Next best thing is the laundromat. That’s where all the people Who would be on the bus if they had the money Hang out. This is my crowd.
“I Ride The Greyhound” —Ellie Schoenfeld

Having my magic finger on the pulse/pulsar, I comment today not on the way we would like the world to be but the way it is. Just over a hundred years ago, Albert Einstein proposed that the single most abundant force in the universe – gravity – was merely a warp in the space-time continuum. Albert suggested that accelerating mass should make ripples in this strange, magical space-time. With the recent discovery and photo imaging of twin black holes approximately 60-kilometer across encircling each other in a cosmic dance (releasing an amount of energy per second measured in the quintillions) one must marvel at Albert’s genius. How could he have been so right so many long years ago while working with what is by today’s standards no real instrumentation at all? It begs the question: Are we actually getting smarter as a species?

This is quickly answered by tuning in at the six o’clock news. Remember, if it bleeds, it leads: Five people shot in a gas station carjacking. Two men drive through the front door of a hookah bar after being ejected. And finally a Moroccan soccer game is interrupted by hundreds of fans rioting and throwing Molotov cocktails in the stands.

Most people can just turn the channel and move on, but not us. Every one of these people, the guilty, the innocent and those who can’t make up their minds, will be coming to our EDs eventually. We are the ones who will see these people in the flesh, and answer sadly, “No, the species is not advancing as a whole.”

Are we at least getting better at understanding our problems? Probably not. Remember that Shakespeare was a small town hick who went to the sixth grade. And Einstein was a mediocre student who worked in the Swiss Patent Office. We don’t know where vision comes from. But we do know that we’re currently struggling with our basic philosophies of parenting and education.

I must after all these years admit I have been living off man’s blatant stupidity and his inhumanity to his fellow man. If kindness and intelligence ever breaks out, we are all out of a job. Close the doors. Shut off the lights. Start doing sports physicals and blood pressure checks because most of our business depends on this sort of insanity. But from what I’ve seen, good news to emergency people, there is little chance that either intelligence or kindness will breakout in the world. So we have what we might call complete job security.

I say this not to be a condescending jerk, but to face the fact that as emergency physicians we are the doctors for the common man. We care for the Greyhound crowd in Ellie Schoenfeld’s poem. These are our people. What we need to do our job is a clear vision of who we are and more importantly, who our patients really are. In the emergency department, all facets come together: the wealthy [a few], the working class [maybe more], the nonworking class, and the absolutely undefinable who represent the most interesting of the lot. This collection of folks, particularly in urban centers, gives us a patient population that is unequalled in all of medicine for both diversity and interest. You are not a true emergency doctor until you learn to love your patients as they are, not for what you think they could be. Remember they came to us for care, not for judgment.

It came to me last year as I was engrossed in celebrating the 150th anniversary of the publication of Alice’s Adventures in Wonderland. I am an unabashed Lewis Carroll [Charles Dodgson] fan. Shortly out of med school, I was able to get a copy of the annotated Alice, which I have kept on my shelf in my office ever since, as a constant source of inspiration. Never mind what the neo-fascist, liberal, de-constructionist literary critics say; Carroll’s mind was the top of the heap in his era. No writer, save Shakespeare and perhaps the authors of the King James Version of the Bible, have given us more quotable quotes and delightful nonsense.

So why Lewis Carroll? What’s his relationship to the emergency department? Simple. In wonderland, like the ED, you are forced to accept most everything. Alice never judges. Alice, like a good emergency person, moves through a kind of Pilgrim’s Progress, going from micro adventure to micro adventure. Like her, we move from exam room to exam room, doing what we can to relieve pain and suffering. Alice is forced to accept an un-birthday party, just as we are expected to believe our patient was beaten up by the famous unknown-but-ubiquitous “Some Dude.” You soon realize in this business that if “Some Dude” and his brother “Dat Dude” ever did finally get arrested, all crime in America would cease.

Alice functioned between two worlds: the upper world, where everything makes conventional sense, and the wonderland, where previous assumptions must be rethought and rational convictions cannot be assumed. Sounds like the Emergency Department to me. This is the place where we practice an almost existential Buddhism in which we achieve what is possible, not necessarily what is the best or even what’s right.

The key to Alice’s success is the key to ours as well: kindness and respect, without naiveté. The Alice books are gloriously free of moralism. Let’s hope our departments can be free as well. No extemporaneous preaching, please. Sometimes love and respect are best expressed by silent restraint.

I came from a background of Episcopalian High Church Anglican/Catholicism. I am well-versed in the Eucharistic presence, the necessity of sacramental baptism and absolution and in the Oxford Movement. None of these concepts should have anything more than a subliminal influence in my ministering to the sick. There are many altars in modernity. But the fundamental force at work in our wonderland of the ER is human dignity in a time of need. Your faith, my faith, even Alice’s faith coexist with a recognition that reasonable [or unreasonable]people may think otherwise.

Trying to project all of our own middleclass value structures on our patients simply will not work. Whatever provides them a faith, it is theirs, and not necessarily ours. We supply the knowledge, the scientific facts. They will supply the structure in how those facts affect their lives. The ultimate shared decision-making is the acknowledgement that the final decision is the patient’s and not ours alone.

Carroll’s characters are our characters. I met Tweedledum and Tweedledee one time in my emergency department at Beyer Hospital. These two were neighbors who were both drinking heavily in their backyards on a warm, summer afternoon when they decided to trim the threefoot hedge which separated their yards. It only seemed natural to them that if a push rotary lawn mower could cut grass, it could certainly trim that hedge between their properties. After starting the infernal machine, they proceeded to lift it up by the wheel mountings on the lower edge of the propeller housing and walked down on each side of the hedge. Well, like most flashes of genius that seem like a good idea while heavily intoxicated, this one quickly went astray when one man stumbled, causing both men to reach into the housing of the mower to hold it up. As the pair were being wheeled to my department, of their collected 20 fingers, five had been fully amputated and six more had been chewed to the point of non-recognition. Tweedledum commented to Tweedledee through his tears: We didn’t even finish that case of beer!

We meet the white rabbit, the red queen, the walrus and the carpenter and of course the mock turtle every single day. Admit it: on many bad afternoon shifts, you must have sat there and thought to yourself that things do proceed “curiouser and curiouser.” And the patients just keep coming, just like in a twisted dream. Our wonderland is an all-too-real absurdity of this world inverted and distilled into an entrancing dreamlike state. We somewhere deep down believe that this is a cosmic joke and somewhere in a parallel universe some other beings are laughing at us. There is no use telling these stories even with the names removed at home because no one we know would believe the ridiculous bizarre images we are describing. When we get home, we dare not speak of these dreams which happen before us.

As I age, I must regret that I did not keep a diary and a photo album of my many adventures in wonderland. I should have come home from each shift and written instead of having a drink. Actually, coming home and writing while having a drink now seems much more reasonable. The writing preserves the dreams; the alcohol helps destroy them.

In truth emergency physicians cannot really afford to remember too clearly or too carefully. Man’s ability to suppress the bad and to mystify and glorify the good makes it possible to go back to wonderland again and again, shift after shift. Too good a memory is too painful even for us to bear.

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